There is a growing shortage of nurses in developed countries,
fuelled by rising life expectancy, increasing chronic health needs and
an ageing nursing workforce. While there can be no debate about the need
for all involved in nurse migration (recruiters, agents and employers)
to behave ethically, perhaps it is time to re-examine the issues and
perspectives of stakeholders in this complex, multifaceted social
phenomenon. New Zealand is a significant exporter of nurses. It is also
a destination country for nurses from poorer, less developed countries
and is well placed, therefore, to understand the wider ethical
implications for nurse migration.

Much has been written about the impact of losing significant
numbers of skilled, trained workers on the health care capacities of
source countries. For many developing countries, nurses play vital roles
in combating significant ill health, especially in rural settings, often
undertaking tasks reserved for doctors in other countries. Where
training of nurses is partly subsidised by tax payers, there have been
demands that these professionals reciprocate the investment by serving
the needy in their own countries. (1)

Female phenomenon

Nurse migration is largely a female phenomenon, and the
independence and accomplishment associated with it can be both
emancipatory and in conflict with roles as wives, daughters and mothers.
(Interestingly, though the costs of training, and the impact of losing
medics are arguably much higher than for nurses, there has been far less
moral panic related to international doctor migration.)

Many countries have experimented with voluntary codes and bans on
aggressive recruitment and with manipulating nursing registration
requirements, as mechanisms to limit over-recruitment from vulnerable
countries. (2) However, these tactics have not only been ineffective in
protecting source countries, they have also actively disadvantaged
international nurses; condemning them to employment in the most poorly
paid and least regulated health sectors. It is in no-one's
interests that highly trained theatre nurses are working as porters or
caregivers on minimum wages. Additionally, some source countries such as
the Philippines (3) and China (4) increasingly deliberately produce
trained nurses as an export commodity--to generate hard currency as part
of national development strategies. Undoubtedly, patients in both the
Philippines and China would have better access to health care if there
were more nurses but it is not the absolute lack of trained staff, but
the lack of funds to employ the staff that underlies the lack of
capacity.

For individual nurses who have invested personally in their
training and registration, the aspirations to work abroad for decent
wages are completely understandable. For New Zealand nurses, the
benefits of having vacancies filled by international colleagues are
often balanced by difficulties caused by the different cultural,
linguistic and professional backgrounds, which can be confusing and time
consuming. Even for a migrant from an English-speaking country, accent,
slang, idiom and culture are surprisingly unfamiliar, and clinical
protocols, scopes of practice, and workplace policies and procedures new
and challenging. It can be distressing to move from one environment
where your skills and experience are prized and respected, to one where
they appear to count for little. Unless tensions and misunderstandings
on both sides are managed well, the potential for personal and
professional damage is large.

In the past, national nursing organisations have perceived the
interests of their members (job security, wages and competition) to be
in conflict with those of migrant nurses. (5) The ICN, while recognising
the potential adverse effects on source countries, argued as long ago as
2001 that: "Career mobility allows nursing to respond to
scientific, technological, social, political and economic changes by
modifying or expanding the roles, composition and supply of nursing
personnel to meet identified health needs." (6) New Zealand's
nurses have a more sophisticated understanding of the economics and
politics of international migration generally, and many have personally
benefited from increased experience and financial gain while working
abroad.

As a country, we have much to gain from access to nurses with
different ideas, new skills, and a passion to work here. Most migrants
are resourceful and resilient and, with the right support, can
contribute to increasing New Zealand's social and economic capital.

The human right of nurses (and all workers) to migrate to further
their careers and assist their families frequently collides with other
political and social imperatives. Identifying and addressing the
causative factors behind nurse migration requires concerted action by
governments in both developed and developing countries. As nurse
migration researcher James Buchan has said: "Careful workforce
planning, end effective recruitment and retention of domestic nurses are
among the most important messages to prevent brain drain from developing
countries. " (7)

In 2007, New Zealand signed the Islamabad Declaration on
Strengthening Nursing and Midwifery, one goal of which was that
"each country must establish policy and practices to ensure
self-sufficiency in workforce production within the limits of its own
resources" (8) Production and retention are equally important.

While New Zealand cannot greatly affect the "pull"
factors for nurses from countries that can ill afford to lose them, it
can, with appropriate political will, remedy the "push"
factors that drive our nurses overseas in search of fair pay, flexible
careers, safe staffing and stimulating and empowering work environments.